The management of formulary information and processes at a retail pharmacy is a time consuming activity that diminishes overall profitability and impacts customer service. This is an expanding business issue as pharmacy claims processors expand the use of 3-tier copays and migration of patient's to higher out-of-pocket liabilities. Additionally, healthcare payers are seeking to offset rising prescription costs. Their approach is multi-fold: use higher copays to push an increasing portion of the financial liability to the patient and influence subsequent patient purchasing decisions; use formularies to influence prescribing and dispensing activities with the goal of driving the decision to a preferred product; and leverage the cost (i.e. purchasing and technology) advantages of “Mail Order” by migrating maintenance medications away from retail.
FIG. 1 shows a flow chart of a typical process by which retail pharmacies submit pharmacy claims to payers and dispense drugs to patients. A pharmacy will be in receipt of a prescription for a patient after the patient or the patient's physician presents the prescription to the retail pharmacy (block 10). The pharmacy will then enter the prescription into a pharmacy practice management system or the like, which document the physician's medication therapy intent for the patient (block 15). The pharmacy will then electronically submit the claim to a pharmacy claims processor, for instance, using the pharmacy practice management system (block 20).
The pharmacy claims processor will adjudicate the claim and generate an electronic response to the pharmacy (block 25). The pharmacist (or another person associated with the pharmacy) will receive the electronic response from the pharmacy claims processor (block 30). If the claim is approved, the pharmacist begins dispensing the drugs (block 45). On the other hand, if the claim is rejected, the pharmacist reviews the response to determine an appropriate action to take (block 40). After the drugs (or medication) is dispensed, the patient pays for the prescription at the pharmacy, which may be a payment for only a partial amount of the total cost of the prescription where insurance or another provider pays for part of the prescription (block 50). The patient then receives the prescription (block 55).
The above-described process is flawed for a variety of reasons including, but not limited to the following reasons. First, at block 15, the pharmacy does not know if a formulary exists or the specifics of the formulary (e.g. preferred vs. non-preferred, patient liability, etc.) before the claim is submitted to the pharmacy claims processor (at block 20). Not knowing the formulary, the pharmacist does not have a chance to influence the dispensing decision with the physician or with the patient. When a pharmacy claim is approved (block 35), the claim response may include a message indicating an alternative product should be considered to reduce the patient's out of pocket spend. However, many pharmacists do not read or interpret free-text message fields of a claim response when a claim is approved by the pharmacy claims processor. Subsequently, the pharmacy associate may be asked by the patient or physician to identify the preferred product when the patient's financial liability is deemed too high. The present invention presents specific formulary information to the pharmacy associate prior to submitting a claim to a pharmacy claims processor.
Additionally, as described at blocks 35 and 40, if a pharmacy claim is rejected, a pharmacist is forced to review the free-from text field associated with the claim response message. Typically, most pharmacy claims processors do not reject a pharmacy claim. Instead, most claims are approved and the patient's out-of-pocket liability used to motivate the patient to switch to a preferred medication within the therapeutic category. Moreover, only after a patient arrives at a pharmacy to pick up their prescription (block 55) do patients typically refute the purchase of the prescription if their out-of-pocket expense is for a higher tier copay. This scenario creates several issues. First, the pharmacist may not have sufficient information to identify the preferred brand drug for the patient or prescriber. Second, the pharmacist has to contact the physician to authorize a different medication if the preferred drug is not a generic for the prescribed drug. Third, the pharmacist has to dispense a replacement prescription if an alternative medication is available and authorized. All of these activities affect pharmacy associate productivity and therefore overall profitability.